Anyone who thinks there is no point in trying to rehabilitate someone with dementia should visit Irene. She would tell them that she was admitted to hospital in January 2003 and transferred to a nursing home before returning to live in her flat in March. But she cannot remember why she was in hospital or anything about the nursing home.

The reality is that Irene was admitted to hospital with heart problems. Her behaviour was "extremely difficult to manage", and she was quickly assessed for admission to a nursing home for people with advanced dementia. Luckily for Irene, she was diverted to a nursing home with a specialist intermediate care wing. Five weeks later her mental condition had stabilised, her cognitive test score had risen to the level indicating mild dementia, she had regained daily living skills, and she went back home.

Clearly, people with dementia can benefit from intermediate care (a buzzword for rehabilitation) and have just as much right to this care as anyone else. But despite the government spending £900m a year on intermediate care since 2000-1, it is difficult to find services that provide intermediate care for people with dementia.

Intermediate care is a government-sponsored programme which promotes rehabilitation through time-limited interventions. It has helped reduce the number of people waiting in hospital for discharge, but so far there has been no significant reduction in the number of older people with mental health problems, especially dementia, waiting for discharge. Why isn't intermediate care reaching this group?

Some answers can be found in a report by the Nuffield Institute for Health which lists 11 reasons why older people with mental health needs have limited access to intermediate care.¹ They include inadequate assessment, skills shortages, cash limits, inadequate home support, and the timescale of six weeks specified in the criteria for intermediate care,² which is not appropriate for many people with mental health needs.

According to Nuffield, many assessments are conducted by staff with little or no mental health experience. Inexperienced assessors are likely to conclude that people with mental health needs cannot improve within six weeks, or even be motivated enough for rehabilitation to be likely.

Here again is the attitude deficit that assumes that people with dementia are not suitable for rehabilitation. Whether it arises through ignorance or prejudice, it is keeping as many as 2,000 people in acute hospital beds - and many more in non-acute beds - who should not be there. As well as the cost implications, these people are denied the right of choice. And because they are not receiving appropriate care, their needs are likely to increase rather than decrease, which will often lead to unnecessary admission to a nursing home specialising in the management of behavioural problems.

The bed-based service that rescued Irene is one of a small number dedicated to rehabilitating people with dementia. Of these, the flagship Saffron House in Bristol, with 14 dedicated beds, takes people who would otherwise have entered specialist nursing homes on a long-term basis. The team takes pride that none of the 46 people discharged in the first year needed to go to a specialist nursing home. Other intermediate care schemes work with people in their own homes, usually by linking specialists such as community mental health nurses to existing intermediate care teams. Both approaches demonstrate the value of rehabilitation for people with dementia.

There are two unique strands of intermediate care in dementia care. "Rescue" is a word often used to point out that staff with skills in treating physical conditions are normally not trained to respond to the needs of a person with dementia. Common events experienced by people with dementia in acute wards include:

• Over-medication.
• Dehydration.
• Under-nourishment.
• Inattention to dietary needs.
• Failure to enter into communication.

The consequence in many cases is that the person becomes labelled as difficult and their mental state deteriorates, while the physical condition for which they were admitted does not receive treatment.

So rescue, or - to use more comfortable wording - care diversion, is an important part of intermediate care for people with dementia. It may need dedicated beds, with access to skills in treating the original physical conditions alongside severe, though temporary, episodes of disturbance.

But most intermediate care is out there in the community rather than in bed provision. A service designed to overcome delayed discharges is of little value unless steps are also taken to prevent such people from being admitted. So the second unique strand is prevention. A preventive service will still need to meet the criteria for intermediate care, so it must be distinguished from wider preventive services by a time limit (defined, but not limited to six weeks) and its focus on identified goals. Once these have been achieved, any continuing support will need to be passed on to mainstream services.

Two initiatives are boosting the move to develop access for people with dementia to intermediate care. The change agent team at the Department of Health is supporting a learning and improvement network that is spreading the word about the few initiatives which are already proving effective.

The second initiative is the issue of a template for intermediate care for people with dementia. This was produced by Devon social services department, its partner agencies and Dementia Voice, with funding from the Performance Fund. The template (see panel, left) is in three parts which identify:

• How intermediate care for people with dementia is different from mainstream intermediate care.
• The framework: aims and interventions.
• Key elements: the essential features of intermediate care for people with dementia.

Part of the work to develop the template included consultation exercises with people with dementia and with carers. Which brings us back to 90-year-old Irene. If you were to visit her, you would have to make an appointment in advance, as she may be giving violin lessons to her friends.

Care template

How Intermediate care for people with dementia is different

• Focuses on abilities not disabilities.
• Can include prevention.
• Often includes diversion from inappropriate care.
• Care processes can take more time.
• Assessment and gaining consent may need special skills.

Framework

• The aim: to enable people with dementia to retain or regain abilities, where their loss would significantly change their quality of life.
• Intervention stages: times of transition and when intervention can prevent breakdown of care.
• Time scales: a rapid response, short-term intervention.

Key Elements

• Individual and person-centred.
• Working with carers.
• Multi-disciplinary.
• Awareness and sharing.
• Consistent with existing practice.
• Maximising independence.
• Prevention and reablement.
• Continuity.
• Scope.
• Flexibility and availability.

The full template can be seen at www.dementia-voice.org.uk/Intermediate_care2.htm

Chris Sherratt is service development officer, Dementia Voice. 

Sue Younger-Ross is head of strategic planning and policy, Devon social services department.  The authors can be contacted at csherratt@dementia-voice.org.uk 

References  

¹ Nuffield Institute for Health, Exclusivity or Exclusion? Meeting Mental Health Needs in Intermediate Care, 2002 

² Department of Health circular, HSC 2001/01: LAC, 2001